06-001463 Fairpay Solutions, Broadspire Services, Inc., And Crum Services vs. Agency For Health Care Administration Status: Closed Recommended Order on Tuesday, July 18, 2006.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

FAIRPAY SOLUTIONS, BROADSPIRE )

SERVICES, INC., and CRUM )

SERVICES, )

)

Petitioners, )

)

vs. ) Case No. 06 - 1463

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent, )

)

and )

)

MIAMI BEACH HEALTHCARE GROUP, )

LTD., d/b/a AVENTURA HOSP ITAL )

AND MEDICAL CENTER., )

)

Intervenor. )

)

ORDER CLOSING FILE

This case is before the undersigned on Aventura Hospital’s

Motion to Relinquish Jurisd iction to Agency For Health Care

Administration for Entry of a Final Order, filed June 30, 2006.

Petitioners filed a response in opposition to the motion on

July 7, 2006. The Agency supports the motion. A hearing was

held on the motion on July 17, 2006.

Section 120.57(1)(i), Florida Statutes, provides that "[a]n

order relinquishing jurisdiction shall be rendered if the

administrative law judge determines from the pleadings,

depositions, answers to interrogatories, and admissions on file,

together with supporting and opposing affidavits, if any, that

no genuine issue as to any material fact exists.” The movant

has the burden to demonstrate that there are no disputed issues

of material fact, and all reasonable doubt as to the existence

of a factual dispu te must be resolved in favor of the non -

movant.

This case involves a reimbursement dispute under Section

440.13(7), Florida Statutes. The case was referred to the

Division of Administrative Hearings based upon the Petition for

Administrative Hearing fi led by Petitioners in response to the

Determination issued by the Agency on March 13, 2006, which

states in pertinent part:

[I]t is not permissible for adjustments to

be made to reimbursement on criteria other

than those specified in the applicable

[reimb ursement manual].

Inasmuch as the carrier has waived all

objections to the petition, the Agency finds

that the [explanation of bill review form]

filed with the petition does not provide a

valid reason for the carrier’s adjustment of

reimbursement.

Based upon the [reimbursement manual] and

the above analysis, it is hereby determined

that the carrier improperly adjusted

payment. The [provider] billed $10,068.00

The correct reimbursement is $7,551.00 (75%

of $10,068.00).

Section 440.13(7), Florida Statute s, provides in pertinent

part:

(a) Any health care provider . . . who

elects to contest the disallowance or

adjustment of payment by a carrier under

subsection (6) must, within 30 days after

receipt of notice of disallowance or

adjustment of payment, p etition the agency

to resolve the dispute. The petitioner must

serve a copy of the petition on the carrier

and on all affected parties by certified

mail. The petition must be accompanied by

all documents and records that support the

allegations contained in the petition.

Failure of a petitioner to submit such

documentation to the agency results in

dismissal of the petition.

(b) The carrier must submit to the agency

within 10 days after receipt of the petition

all documentation substantiating the

carr ier's disallowance or adjustment.

Failure of the carrier to timely submit the

requested documentation to the agency within

10 days constitutes a waiver of all

objections to the petition.

(c) Within 60 days after receipt of all

documentation, the agen cy must provide to

the petitioner, the carrier, and the

affected parties a written determination of

whether the carrier properly adjusted or

disallowed payment. The agency must be

guided by standards and policies set forth

in this chapter, including all a pplicable

reimbursement schedules, practice

parameters, and protocols of treatment, in

rendering its determination.

* * *

§ 440.13(7), Fla. Stat. (emphasis supplied).

The parties did not cite any judicial decisions construing

Section 440.13(7)(b), Florida Statutes. That provision was not

implicated in any of the administrative decisions provided at

the motion hearing because, in each of those cases, 1 the carrier

responded to the petition filed by the provider. The

undersigned’s research did not lo cate any judicial or

administrative decisions in which Section 440.13(7)(b), Florida

Statutes, was implicated. Thus, the issue framed by the motion

appears to be one of first impression.

It is undisputed that the provider, Aventura Hospital,

filed a peti tion with the Agency and properly served the

petition in accordance with Section 440.13(7)(a), Florida

Statutes. It is also undisputed that no response to the

petition was filed by the employer/carrier or anyone on its

behalf pursuant to Section 440.13(7) (b), Florida Statutes. See

Affidavit of Lori Intravichit, at ¶ 9 (filed July 10, 2006).

Petitioners contend that there are disputed issues of

material fact regarding whether the Determination issued by the

Agency on Aventura Hospital’s petition is cons istent with the

“standards and policies set forth in [Chapter 440, Florida

Statutes], including all applicable reimbursement schedules,

practice parameters, and protocols of treatment” as required by

Section 440.13(7)(c), Florida Statutes. However, Petiti oners do

not have standing to raise the issue in this proceeding because

they “waive[d] all objections to the petition” by not filing a

response to the petition with the Agency. 2 See § 440.13(7)(b),

Fla. Stat. Therefore, it is

ORDERED that:

1. The f inal hearing scheduled for August 17 - 18, 2006, is

hereby cancelled.

2. The file of the Division of Administrative Hearings in

this case is closed, and jurisdiction is hereby relinquished to

the Agency for entry of a final order consistent with its

March 13, 2006 Determination.

DONE AND ORDERED this 18th day of July, 2006, in

Tallahassee, Leon County, Florida.

S

T. KENT WETHERELL, II

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

123 0 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675 SUNCOM 278 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 18th day of July, 2006.

ENDNOTES

1/ Specialty Ris k Services v. Agency for Health Care Admin. , 25

FALR 3973 (AHCA 2003); CNA Insurance Cos. v. Agency for Health

Care Admin. , 24 FALR 1304 (AHCA 2003); Wyatt Bros. Construction

v. Dept. of Labor & Employment Security , DOAH Case No. 00 - 2572,

Agency Case No. 0 1 - 025 - DWC (Partial Recommended Order Dec. 13,

2000; Recommended Order May 10, 2001; Final Order June 11, 2001).

2/ In light of this ruling, it is not necessary to determine

whether Fairpay and Broadspire are proper parties in this

proceeding. But cf. Fu rtick v. William Shults Contractor , 664

So. 2d 288, 290 (Fla. 1st DCA 1995) ("[T]he health care provider

(or facility) and the employer/carrier are the parties with the

legal interest affected by utilization review."). It is also

unnecessary to determine whether the Agency satisfied its

obligations under Section 440.13(7)(c), Florida Statutes, by

simply reviewing the bills submitted by the provider against the

reimbursement manual (as Aventura Hospital and the Agency contend

is appropriate) or whether the Agency must undertake a more

comprehensive evaluation even if the carrier failed to do so (as

Petitioners contend is required).

COPIES FURNISHED:

Joanna Daniels, Esquire

Agency for Health Care Administration

Workers' Compensation Medical Services

200 Ea st Gaines Street

Tallahassee, Florida 32399 - 4229

Tamela I. Perdue, Esquire

Stiles, Taylor & Grace, P.A.

Post Office Box 1140

Tallahassee, Florida 32301

Richard M. Ellis, Esquire

Rutledge, Ecenia, Purnell &

Hoffman, P.A.

215 South Monroe Street, Suite 420

Post Office Box 551

Tallahassee, Florida 32304 - 0551

Richard Shoop, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Mail Station 3

Tallahassee, Florida 32308

William Roberts, General Counsel

Agency for Health Care Administratio n

Fort Knox Building, Suite 3431

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308